When form is completed, please send it (along with a copy of the doctor's prescriptions) by:Fax: 1-866-793-2987, orEmail:SaveRxCanada.to
PLEASE FILL OUT ALL FIELDS COMPLETELY
|Important! For optimal health and best results of any medication it is important to have had a physical examination in the past 12 months. Have you had one? Y___ N___ (If not, we will require that you schedule an appointment with your physician.)|
Date of Birth
Postal/Zip Code Email
Phone (Home) Phone (Work)
ALTERNATE SHIPPING ADDRESS
Alternate Shipping Address
Primary Physician Name
Name of Clinic / Doctors Office
Do you require child resistant containers for your medication? Y or N
|Please indicate if you would like to receive counseling:
Yes ____ No ____
|Have you previously filled out a Medical
Questionnaire? Yes _____ No
____ Not Sure ____
If YES are there any changes Yes (please specify)
__________________________________________________ No __________ |
NOTE: It is only necessary to fill out the Questionnaire once a year, as long as there are no changes. Please indicate if you / your family has a history of any of the following:
|Patient Family Medical History|
|If you answered YES to questions 1 - 7, please
explain in more detail, if necessary|
|Patient Medical History|
|If you answered YES to any of the above questions please elaborate in the box below (i.e., duration of illness, any treatment or surgery received, amount smoked and for how long)|
|I hereby confirm that the above information is true and
accurate as of the date hereof.|
Patient's Full Legal Name (Print)
Patient's Signature ____________________________________________
Please list all medications you are currently taking and the condition for which they are prescribed.
|Medication & Strength||Daily dosage (eg.1 tab daily)||Condition|
|MEDICATIONS BEING ORDERED TODAY|
|(If your order does not fit on the space provided, please attach them on a separate sheet) Add Shipping||$8|
|Total (US $)||$______________|
|VISA _____||MASTERCARD _____|
|Card Holder Name (on Card) ___________________________________________________|
|Card Holder Address ___________________________________________________|
|Province/State||__________________||Credit Card Number||__________________|
|Postal/Zip Code||__________________||Credit Card Expiration||__________________ (eg. 11/06)|
|* CVV2 # Number||__________________|
|* (required for credit card transactions - The CVV2 verification number is a 3-digit (MC & Visa) number printed on the back of your credit card. It appears on the right hand side of the card.)|
|Unless otherwise notified in writing, I hereby authorize SaveRxCanada.to to charge my credit card for the cost of all present and future medications ordered plus all associated shipping costs.|
No prescription(s) will be filled until a signed and dated copy of this document and a completed Patient Profile have been received by SaveRxCanada.to
I, as the undersigned, being over the age of 18, hereby covenant, represent, warrant and confirm to, and acknowledge and agree with, SaveRxCanada.to and its affiliates, related companies, subsidiaries and parent company, and to the Prescription Processing Centre identified herein (if any), as follows:
Disclosure and Representations
The pharmaceutical(s) to be delivered to me were prescribed by a
doctor licensed to practice medicine in the country, state
or other applicable jurisdiction in which I reside or where I sought treatment, and were lawfully obtained from that physician.
Any medication obtained for me by SaveRxCanada.to will be used strictly according to the instructions provided by the physician who prescribed the medication, and only by the person for whom the pharmaceutical(s) were prescribed.
I can make my own medical decisions according to the law of the place where I reside. The prescription(s) I am requesting SaveRxCanada.to to assist me in obtaining has not been altered in any way nor has it been filled prior to submission to SaveRxCanada.to. I agree to immediately destroy all copies of my prescription(s) once it has been filled.
I am not seeking or relying on any medical information from SaveRxCanada.to or
the Prescription Processing Centre, and I have
consulted a qualified physician licensed where I obtained the prescription within the last year.
I will immediately contact the physician who provided my prescription included with this order in the event I suffer any unexpected side effects from any medication obtained for me by SaveRxCanada.to.
I understand that it is my responsibility to have regular physical examinations by my primary US licensed physician that is responsible for my care including all suggested testing to ensure that I have no medical problems which would constitute a contradiction to me taking the medications being prescribed.
I acknowledge that SaveRxCanada.to's employees and agents have relied on the information and documentation that I am providing (including the Patient Profile) and I represent and confirm that I have fully disclosed all pertinent information and documentation to SaveRxCanada.to. I agree to notify SaveRxCanada.to of any changes to my physical or medical condition by providing an updated Patient Profile.
Authorization and Consent
I hereby authorize and appoint SaveRxCanada.to, as my agent and attorney for the limited purpose of taking all steps and signing all documents on my behalf necessary to obtain a prescription in Canada that is the equivalent of the prescription that I sent to SaveRxCanada.to, to the same extent as I could do personally if I were present taking those steps and signing those documents myself. This authorization shall include, but not be limited to: collecting personal health information about me; collecting similar information from my prescribing physician or pharmacist, and disclosing that personal health information to SaveRxCanada.to employees, agents and service providers including the Canadian physician being retained on my behalf, as required, for the limited purpose of obtaining the Canadian prescription.
I hereby specifically acknowledge that I am aware that SaveRxCanada.to and the Prescription Processing Centre will be transmitting my personal health information by electronic means (for example fax, secure internet) to its employees, agents, affiliates and service providers including the Canadian physician retained on my behalf. I understand that the use of electronic means will enhance the efficiency and timeliness of processing my order. I also understand that SaveRxCanada.to and the Prescription Processing Centre, as custodians of my personal health information will take all appropriate precautions to protect my personal health information from improper disclosure or use. I hereby consent to the transmission by SaveRxCanada.to and the Prescription Processing Centre of my personal health information by electronic means.
If I was directed to SaveRxCanada.to's services through the Prescription Processing Centre, or some other intermediary (for example Pharmacy Benefit Manager, Health Management Organization, or other healthcare service provider), I hereby authorize SaveRxCanada.to to release the following data to such an intermediary:
A numerical identifier indicating that I was a patient referred from that source; financial information that will permit the processing of any claims on my behalf.
It is my understanding that all such intermediaries will enter into
Confidentiality Agreements where they agree to abide by
the privacy policies of SaveRxCanada.to relating to the protection of my personal health information. I specifically consent to the
transmission of the forgoing information by electronic means.
I authorize and appoint SaveRxCanada.to as my agent and attorney for the
purpose of taking all steps and signing all documents on my behalf
necessary to package or re-package the pharmaceutical(s) and to deliver
them to me, to the same extent as I could
do if I were personally present taking those steps and signing those documents myself, and as if I had shipped the
prescribed pharmaceutical(s) to my own address.
I acknowledge and agree that I initiated a consultation with SaveRxCanada.to and that SaveRxCanada.to is not located in the United States. I also acknowledge that the pharmacists working for SaveRxCanada.to and the physicians contracted by SaveRxCanada.to on my behalf are located and licensed to practice medicine or pharmacy in Canada and that all services that I receive from any such Canadian physician and pharmacist are being received in Canada.
I further agree that any and all agreements reached or contracts formed throughout the course of the relationship between me and SaveRxCanada.to shall be deemed to be made in the Province of Manitoba, Canada and accordingly shall be governed by the laws of the Province of Manitoba and the laws of Canada applicable to such contracts and agreements.
I agree that any dispute that arises between me and SaveRxCanada.to, its officers, directors, employees, agents and contractors shall be governed by the laws of the Province of Manitoba and the laws of Canada applicable to contracts formed in Manitoba, and I agree that the courts of the Province of Manitoba shall have sole and exclusive jurisdiction over any such dispute.
Purchase and Sale Terms
SaveRxCanada.to will charge my credit card the following amounts:
The medication price and shipping (in US dollars) as posted on the
SaveRxCanada.to web site on the day SaveRxCanada.to receives my order; and in
the event my payment is not authorized, SaveRxCanada.to has the right to cancel my order and attempt to provide me with notice of
The pharmaceutical(s) will not be packaged in child protected packaging, unless requested by me on the Patient Questionnaire.
SaveRxCanada.to shall be entitled to substitute a brand name prescription drug with a generic prescription drug, where available in accordance with the Manitoba Drug Standards and Therapeutic Formulary, unless the physician has indicated that there be "no substitution". That once purchased and shipped, no pharmaceutical product may be returned or exchanged.
SaveRxCanada.to reserves the right to refuse to assist me in obtaining any
order in its sole discretion, in which event I will be entitled to
a refund for monies paid for such order.
SaveRxCanada.to does not provide its agency or attorney services as a substitute for healthcare or the advice of the customer's primary care physician.
SaveRxCanada.to will not exchange medication or return any monies paid once an
order is filled, unless the medication provided to me
by the supplying pharmacy does not correspond with my prescription.
The Prescription Processing Centre is acting as my agent in
completing the forms and taking such other actions as are necessary to
request SaveRxCanada.to to send me the prescriptions I am requesting, and is not the
agent, express or implied, of SaveRxCanada.to. In this regard, but without limiting
the generality of the foregoing, I acknowledge and agree that the
Prescription Processing Centre does not have the authority to assume or
create any obligation whatsoever, expressed or implied, in the name
of SaveRxCanada.to, or to otherwise bind SaveRxCanada.to in any manner whatsoever.
I have read and understood the terms and conditions set out in this Agreement and agree, on behalf of myself, my heirs, successors, administrators and assigns to be bound by these terms and conditions.
Signed this _______________ day of _______________, 2018.